Professional Documents
Culture Documents
G DevelopDentition
G DevelopDentition
Adopted
1990
Revised
1991, 1998, 2001, 2005, 2009
Purpose
The American Academy of Pediatric Dentistry (AAPD) recognizes the importance of managing the developing dentition
and occlusion and its effect on the well-being of infants, children, and adolescents. Management includes the recognition,
diagnosis, and appropriate treatment of dentofacial abnormalities. This guideline is intended to set forth objectives for
management of the developing dentition and occlusion in
pediatric dentistry.
Methods
This revision is based upon a new MEDLINE search using
the following parameters: Terms: ankylosis, anterior crossbite,
Class II malocclusion, Class III malocclusion, dental crowding,
ectopic eruption, impaction, obstruction sleep apnea syndrome
(OSAS), occlusal development, oligodontia, oral habits, posterior crossbite, space maintenance, and tooth size/arch length
discrepancy; Fields: all; Limits: within the last 10 years,
humans, English, and birth through age 18. Papers for review
were chosen from this search and from references within selected articles. When data did not appear sufficient or were
inconclusive, recommendations were based upon expert and/or
consensus opinion by experienced researchers and clinicians.
Background
Guidance of eruption and development of the primary, mixed,
and permanent dentitions is an integral component of comprehensive oral health care for all pediatric dental patients. Such
guidance should contribute to the development of a permanent dentition that is in a stable, functional, and esthetically
acceptable occlusion. Early diagnosis and successful treatment
of developing malocclusions can have both short-term and
long-term benefits while achieving the goals of occlusal
harmony and function and dentofacial esthetics.1-4 Dentists
have the responsibility to recognize, diagnose, and either
appropriately manage or refer abnormalities in the developing
dentition as dictated by the complexity of the problem and
the individual clinicians training, knowledge, and experience.5
Many factors can affect the management of the developing dental arches and minimize the overall success of any
treatment. The variables associated with the treatment of the
developing dentition that will affect the degree to which treatment is successful include, but are not limited to:
chronological/mental/emotional age of the patient
and the patients ability to understand and cooperate
in the treatment;
intensity, frequency, and duration of an oral habit;
parental support for the treatment;
compliance with clinicians instructions;
craniofacial configuration;
craniofacial growth;
concomitant systemic disease or condition;
accuracy of diagnosis;
appropriateness of treatment.
A thorough clinical examination, appropriate pretreatment
records, differential diagnosis, sequential treatment plan, and
progress records are necessary to manage any condition affecting
the developing dentition.
Clinical examination should include:
1. facial analysis to:
a. identify adverse transverse growth patterns includ ing asymmetries (maxillary and mandibular);
b. identify adverse vertical growth patterns;
c. identify adverse sagittal (anteroposterior) growth
patterns and dental anteroposterior (AP) occlusal
disharmonies;
d. assess esthetics and identify orthopedic and ortho dontic interventions that may improve esthetics and
resultant self-image and emotional development.
2. intraoral examination to:
a. assess overall oral health status;
b. determine the functional status of the patients
occlusion.
3. functional analysis to:
a. determine functional factors associated with the
malocclusion;
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2.
3.
and incisors; (5) holding of leeway space; (6) cross bites; and (7) adverse skeletal growth. Treatment
should take advantage of high rates of growth and
prevent worsened adverse dental and skeletal growth.
3. Mid-to-late mixed dentition stage: Intervention for
ectopic teeth may include extractions and space mainte nance to aid eruption and reduce the risk of need for
surgical bracket placement and orthodontic traction.
Intervention for treatment of skeletal disharmonies
and crowding may be instituted at this stage.
4. Adolescent dentition stage: In full permanent denti tion, final orthodontic diagnosis and treatment can
provide the most functional occlusion.
5. Early adult dentition stage: Third molar position or
space can be evaluated and, if indicated, the tooth
removed. Full orthodontic treatment should be rec ommended if needed.
Recommendations
Oral habits
General considerations and principles of management: The habits
of nonnutritive sucking, bruxing, tongue thrust swallow and
abnormal tongue position, self-injurious/self-mutilating behavior, and airway obstruction (OSAS) are discussed in this
guideline.
Oral habits may apply forces to the teeth and dentoalveolar structures. The relationship between oral habits and unfavorable dental and facial development is associational rather than
cause and effect.15-17 Habits of sufficient frequency, duration,
and intensity may be associated with dentoalveolar or skeletal
deformations such as increased overjet, reduced overbite, posterior crossbite, or long facial height. The duration of force is
more important than its magnitude; the resting pressure from
the lips, cheeks, and tongue has the greatest impact on tooth
position, as these forces are maintained most of the time.18,19
Nonnutritive sucking behaviors are considered normal in
infants and young children. Prolonged nonnutritive sucking
habits have been associated with decreased maxillary arch width,
increased overjet, decreased overbite, anterior open bite, and
posterior crossbite.16,18,19 As preliminary evidence indicates that
some changes resulting from sucking habits persist past the
cessation of the habit, it has been suggested that early dental
visits provide parents with anticipatory guidance to help their
children stop sucking habits by age 36 months or younger.16,18,19
Bruxism, defined as the habitual nonfunctional and forceful contact between occlusal surfaces, can occur while awake
or asleep. The etiology is multifactorial and has been reported
to include central factors (eg, emotional stress,20 parasomnias,21 traumatic brain injury,22 neurologic disabilities 23) and
morphologic factors (eg, malocclusion24, muscle recruitment25).
Reported complications include dental attrition, headaches,
temporomandibular dysfunction, and soreness of the masticatory muscles.20 Preliminary evidence suggests that juvenile
bruxism is a self-limiting condition that does not progress to
adult bruxism.26 The spectrum of bruxism management ranges
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metal orthodontic separators can be placed to wedge the permanent first molar distally.16 For more severe impactions,
distal tipping of the permanent molar is required. Tipping
action can be accomplished with brass wires, removable appliances using springs, fixed appliances such as sectional
wires with open coil springs, sling shot-type appliances,60 a
Halterman appliance,61 or surgical uprighting.62
Early diagnosis and treatment of impacted maxillary
canines can lessen the severity of the impaction and may
stimulate eruption of the canine. Extraction of the primary
canine is indicated when the canine bulge cannot be palpated
in the alveolar process and there is radiographic overlapping of
the canine with the formed root of the lateral during the mixed
dentition.63 Even when the impacted canine is diagnosed at a
later age (11 to 16), if the canine is not horizontal, extraction
of the primary canine lessens the severity of the permanent
canine impaction and 75 percent will erupt.64 Extraction of the
first primary molar also has been reported to allow eruption
of first bicuspids and to assist in the eruption of the cuspids.
This need can be determined from a panoramic radiograph.61,65
Bonded orthodontic treatment normally is required to create
space or align the canine. Long-term periodontal health of
impacted canines after orthodontic treatment is similar to
nonimpacted canines.68
Treatment of ectopically erupting incisors depends on
the etiology. Extraction of necrotic or over-retained pulpallytreated primary incisors is indicated in the early mixed dentition.58 Removal of supernumerary incisors in the early mixed
dentition will lessen ectopic eruption of an adjacent permanent
incisor.47 After incisor eruption, orthodontic treatment involving
removable or banded therapy may be needed.
Objectives: Management of ectopically erupting molars, canines,
and incisors should result in improved eruptive positioning of
the tooth. In cases where normal alignment does not occur,
subsequent comprehensive orthodontic treatment may be necessary to achieve appropriate arch form and intercuspation.
Ankylosis
General considerations and principles of management: Ankylosis is a condition in which the cementum of a tooths root
fuses directly to the surrounding bone. The periodontal ligament
is replaced with osseous tissue, rendering the tooth immobile to
eruptive change. Ankylosis can occur in the primary and permanent dentitions, with the most common incidence involving
primary molars. The incidence is reported to be between seven
percent and 14 percent in the primary dentition.49 In the
permanent dentition, ankylosis occurs most frequently following luxation injuries.67
Ankylosis is common in anterior teeth following trauma
and is referred to as replacement resorption. Periodontal ligament cells are destroyed and the cells of the alveolar bone
perform most of the healing. Over time, normal bony activity
results in the replacement of root structure with osseous tissue.67
Ankylosis can occur rapidly or gradually over time, in some
cases as long as five years post trauma. It also may be transient
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